Tag Archives: empathy

Kellie Collins, a licensed professional counselor (LPC) who runs a group private practice in Lake Oswego, Oregon, experienced her first panic attack when she was 14. She remembers suddenly feeling cold, losing sensation in her hands and her heart beating so rapidly that it felt like it was going to leap out of her chest — all for no readily apparent reason.

“I thought I was dying. That’s what it felt like,” Collins says. “It was the worst experience of my life up to that point. It felt like it lasted forever, even though it was just a few minutes. Afterward, I was left with a feeling that I had no control.”

When Collins subsequently experienced more panic attacks, the situation was exacerbated by a close family member who didn’t understand what was happening. The family member suggested that Collins might be having the panic attacks on purpose, to get attention.

Collins’ life changed for the better in high school, when she began seeing a counselor. She learned not only that her panic attacks were manageable but also that she wasn’t to blame for their occurrence.

“Hearing that I didn’t cause this and that it wasn’t my fault set me on the path to get better. It made all the difference,” says Collins, a member of the American Counseling Association. “The biggest thing [counselors can do] is to validate the client’s experience. What they experience is real and not under their control in that moment — and it’s terrifying.”

‘Fear of the fear’

In addition to overwhelming feelings of fear, panic attacks are usually marked by shortness of breath or trouble breathing and a rapid heartbeat. Other physical symptoms can include sweating (without physical exertion), a tingling sensation throughout the body, feeling like your throat is closing up or feeling that you’re about to pass out, explains Zachary Taylor, an LPC and behavioral health director at a health center in Lexington, Virginia. Symptoms vary, however. “I’ve never had two patients describe it the same way,” he says. (Taylor refers to patients instead of clients because he works at a medical health center.)

According to the National Institute of Mental Health (NIMH), an estimated 4.7 percent of adults in the United States experience panic disorder at some point in their lives. The past-year prevalence was higher among females (3.8 percent) than among males (1.6 percent).

Panic disorder is marked by recurring, unexpected panic attacks (or, as NIMH describes, “episodes of intense fear” that are “not in conjunction with a known fear or stressor”). People who experience panic disorder typically worry about having subsequent attacks, even to the point of changing behavior to avoid situations that might cause an episode.

“It’s such a jarring and uncomfortable experience, and it feels so much like a real medical emergency, that they begin to fear the sensations themselves. This fear of the fear is what drives panic disorder,” explains Taylor, a member of ACA. “If it gets too bad, they begin to arrange their life around trying not to experience anything that might resemble or trigger any of those feelings that are associated with a panic attack, and it becomes a vicious cycle.”

At the same time, panic attacks can occur in people who do not have a panic disorder diagnosis. Although panic attacks are often coupled with stress, trauma or anxiety-related issues, they can also occur in clients without complicating factors, says Collins, who notes that she has seen clients who experienced their first panic attack in their 50s or 60s.

“They can happen even when life is going well and have no apparent reason. … Some people have them for a period of time in life and then never have them again, while others will have them throughout life,” she says. In addition, significant life changes, such as getting married, starting retirement or having a child, can trigger recurrences in clients who previously were able to manage their panic attacks, Collins adds.

Among clients with mental illness, panic attacks can co-occur with depression, anxiety, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobias (particularly emetophobia, or fear of vomiting) and other diagnoses. Taylor says they can also be associated with a medical or physical issue.

“One of the most overlooked problems that can lead to developing panic is chronic sleep deprivation or insomnia,” he says, explaining that a lack of sleep can overexaggerate the fearful thoughts related to panic. When treating panic attacks, counselors should ask clients about their sleep habits within the first few sessions, Taylor advises. Counselors can also remember the acronym CATS and ask clients about their consumption of caffeine, alcohol, tobacco and sugar — all of which can worsen the feelings associated with panic attacks, he adds.

Learning coping skills and identifying triggers

Clients who come to counseling after experiencing a panic attack may start therapy without understanding the complexity of panic attacks or harbor feelings of shame or embarrassment about succumbing to panic seemingly out of the blue, Collins says.

It is sometimes helpful to explain to clients that during a panic attack, their body is launching into the fight-or-flight mode that is part of their biological wiring, Collins says. However, in this case, there is no tiger chasing them.

“I like to say that [a panic attack] is tripping the sensor, like when a leaf falls on your car and the alarm goes off. It trips the sensor, but your car doesn’t know” that there isn’t any actual danger, she explains. Collins says it also can be helpful to assure clients that “it will never be as bad as those first few times when you didn’t know what was happening to you.”

To identify triggers, Collins suggests walking clients through the months, days and hours that led up to their first panic attack — but only when the individual is ready to relive the experience, she adds. Some triggers can be easily identifiable, such as a spike in work-related stress or the loss of a loved one. Other triggers may be less obvious, meaning more work will need to be done to unpack the experience later in therapy.

“I like to make sure clients have really solid coping skills before they work on the underlying stuff that might be contributing” to their panic attacks, such as trauma, Collins says. “Spend the first few sessions identifying what’s been going on. Once they’re confident and capable of managing and getting through an attack, then ask about what might be contributing” to the attacks occurring.

Outside of session, counselors can encourage clients to devote time to journaling, relaxation, deep breathing and counting exercises that can boost self-reflection and change negative thought processes, Collins suggests.

Counselors can also equip clients with coping mechanisms such as mindfulness to help them remain calm and feel more in control in the event of a panic attack. Collins often gives her clients a small stone to carry with them and hold in their hand when a panic attack strikes. She tells them to focus on the stone and describe it to themselves — is it rough, smooth, cold, heavy?This can help divert their attention from the panicky sensations, she explains. The same technique can be followed using car keys, a coffee mug or whatever else clients can hold in their hands that wouldn’t readily draw undue attention from others, she adds.

Clients can also develop mantras to remind themselves in the moment that even though a panic attack feels all-consuming, it is a finite experience. Among the phrases Collins suggests as being helpful:

“I’ve gotten through this before.”

“This is only temporary.”

“Even though this feels like it’s going to last forever, it will end; it always does.”

Collins acknowledges, however, that “once it gets to a certain point, these things don’t work. You have to accept it for what it is when you’re in the middle of an attack. You have to ride the wave, accepting that it will be temporary and it will go away.”

“Sometimes, even getting angry at the panic attack can help,” she adds. “When [people] allow themselves to accept that anger, it takes away some of the power of the attack itself. Admit that it stinks but it’s something you can get through.”

Uncomfortable but not dangerous

Thinking that a panic attack can be halted or avoided by using breathing or relaxation techniques is a misconception, according to Taylor. Those methods are often the first choice of well-meaning practitioners, but Taylor argues that “it sends a subtle message to the patient that what you’re experiencing is dangerous and we need to do something to prevent it.”

“The first thing you need to do is teach [clients] that what [they are] experiencing is uncomfortable but not dangerous,” he says. “It’s your avoidance of the uncomfortable feelings, and trying to stop it, that has unintentionally made it worse. When it comes to symptoms of panic, trying to suppress or avoid those symptoms is the exact opposite of what you want to do.”

Diaphragmatic breathing and other relaxation techniques can be helpful to manage anxiety, Taylor clarifies, but they won’t stop the symptoms of a panic attack altogether. “The only way to truly stop it is to become accustomed to the feelings” and to understand that a panic attack is not dangerous, he adds.

Taylor finds the DARE method developed by author Barry McDonagh particularly helpful. The technique focuses on overcoming panic with confidence rather than employing futile attempts to calm down, Taylor says. The four tenets of DARE are:

Diffuse: Using cognitive diffusion, counselors can teach clients to deflect and disarm the fearful thoughts that accompany panic attacks. The thoughts that flood people’s minds during these episodes are just that — thoughts — and are not dangerous, Taylor explains. “Teach them to say ‘so what?’ to their thoughts: ‘What if I embarrass myself or pass out or throw up? So what?’ Take the edge off that thought by not only demoting it but separating ourselves from the thought: ‘It’s not me. I didn’t put it there.’ Teach patients to say to themselves, over and over, ‘This sensation is uncomfortable but not dangerous.’ Think of it like a hiccup. It’s uncomfortable but not dangerous. There’s nothing medically wrong. The more you focus on it, the more uncomfortable it gets.”

Allowfor psychological flexibility: It is more important that individuals allow and become comfortable with their negative associations than it is to try to get rid of them, Taylor says.

Run toward the symptoms: Moving toward feelings of discomfort is antithetical to human instinct, but in the case of panic attacks, it can actually be an effective tactic. Taylor teaches people who deal with panic attacks to tell their bodies to “bring it on. Ask your heart: ‘Give me more. Let’s see how fast you can beat.’ One of the fastest ways to stop a panic attack, ironically, is to ask for more and try and make it worse. It’s the resistance to the sensations that makes it stick around.”

Engage: Teach clients to engage in the moment once the panic attack has peaked and is starting to wind down. This is when grounding and mindful exercises can be helpful, Taylor says. “What’s important is to focus on right here and right now. That will help you continue to move forward and get unstuck,” he adds.

An attachment approach

All of the counselors interviewed for this article noted that cognitive behavior therapy (CBT) is an effective, tried-and-true method to support clients who experience panic attacks by helping them refocus the fearful and overexaggerated thoughts that accompany the experience.

Linda Thompson, an LPC and licensed marriage and family therapist in Florida, finds that using CBT through the lens of attachment theory can be particularly helpful in addressing panic attacks. That holds especially true for clients who struggle with feelings of abandonment or rejection or have experienced attachment trauma, including the loss of a loved one or caretaker. Counselors can identify clients who might benefit from attachment work by asking questions at intake regarding past relationships and loss, Thompson says.

“If they are the kind of person who is very relationship-oriented and attachment is very important to them or there is trauma there, that has to be brought into the conversation,” says Thompson, an associate professor at Argosy University with a private practice in the Tampa area.

Thompson suggests that counselors invite someone to whom the client is attached, such as a partner or a spouse, into the therapy sessions (with the client’s consent). The practitioner can prompt discussion that helps the client share some of the inherent fears that he or she is harboring. Often, Thompson says, the partner’s response to this sharing is “I had no idea you felt that way. How can I help?”

From there, counselors can introduce techniques that the client and the client’s attachment figure can use together when the client is feeling anxious, Thompson says. Eye contact, hand holding and other physical connections can be particularly helpful. “It’s making it about connecting,” she explains.

Once they understand that their loved one’s worry and panic are spurred by issues related to relationships or a fear of isolation, friends and family members can be better prepared to respond differently when the person begins to struggle. If the client is willing, counselors can play a role in training the individual’s support system to help with attachment-oriented responses. For example, if a client wakes up in the middle of the night feeling panicked, a spouse or partner could respond by rubbing the person’s back or whispering affirmations such as “You’re not alone,” “I’m here” or “We’re going to get through this together,” Thompson says.

Attachment-oriented clients may also benefit from learning to do breathing techniques with someone to whom they are attached, Thompson adds. For example, a client may start to feel the symptoms of a panic attack while driving. Relying on techniques learned in session, the client would pull the car over and focus on their child in the backseat — holding the child’s hand, making eye contact and breathing together. The physical touch will boost oxytocin, a hormone connected to social bonding and maternal behavior, Thompson explains.

Thompson also suggests that these clients try yoga to help with relaxation and self-control. She says the practice is more beneficial if it involves a social aspect, so she recommends that clients practice yoga in a class with other people instead of alone at home.

Similarly, Thompson suggests helping attachment-oriented clients build a “tribe” or circle of support beyond the counselor. This is especially important for those who have lost a spouse or partner and those who are more susceptible to isolating themselves. Counselors can guide clients in finding connections that are personally meaningful to them, whether that is through participation in spiritual or religious activities, volunteer work or other community groups such as a book club. Focusing on relationships rather than the physical symptoms of a potential panic attack can help these clients feel less vulnerable, says Thompson, a past president of both the Pennsylvania Counseling Association and the International Association of Addictions and Offender Counselors, a division of ACA.

Thompson recalls one client who struggled so acutely with panic attacks and a fear of losing her loved ones that it kept her from leaving the house for two years. CBT alone wasn’t helping, so Thompson added attachment techniques to their therapy work together.

After a substantial amount of in-session exploration, Thompson discovered that the client’s panic attacks were tied to family-of-origin issues. The physical feelings the client experienced during her panic attacks were in the same part of the body where one of her parents had experienced a significant health problem.

In addition to conducting one-on-one therapy, Thompson included the client’s husband in sessions. They worked together on attachment-focused techniques, and, eventually, the couple was able to go outside of the home for the first time in a long while to celebrate their anniversary.

To prepare, they created notecards with attachment-focused feelings and reminders, such as what their first date felt like. They referred to the notecards throughout the evening and connected consistently via holding hands and making eye contact.

After the date, the client reported to Thompson that instead of thinking of where the exits were in the restaurant, as she would have done previously, she remained focused on the man — her husband — in front of her.

Thompson urges counselors to remain open to adding attachment theory or other complementary methods on top of go-to techniques such as CBT to reach clients who are experiencing panic attacks. “Expand your toolbox,” she says. “A person’s fear, the fear that is triggering panic, can have multiple origins. Help the client to find the source of their fear, and work on that. … Broaden your perspective to recognize that human beings have to be attached with people, no matter what the disorder. Ask, ‘How do I make sure the social needs of my client are being met?’”

Controlled exposure

Taylor knows firsthand how terrifying a panic attack can feel. He began experiencing anxiety in his teens and early 20s that intensified to the point of daily panic attacks.

When things were at their worst, he would often go to the emergency room of his local hospital. He wouldn’t register as a patient but would simply sit in the waiting room, knowing that those uncomfortable, uncontrollable feelings would eventually overtake him again. “Sometimes [I would go] because I was having a panic attack, or other times it was just because I felt I might have a panic attack,” Taylor recalls.

Eventually, Taylor did check himself into the hospital, and a doctor explained that he was going to be OK. That was the life-changing encounter that put him on the path to getting help; he credits medication and therapy for helping him overcome his panic attacks. The experience also inspired him to become a counselor.

This personal history plays into his work with clients. As a specialist in treating chronic anxiety and panic, he often emphasizes to clients that feelings of fear and excitement share the same neurological pathways. “It’s just our perception that makes them different. … You have to be able to ride the waves of panic without resisting it,” he says.

In addition to teaching clients to tolerate and deflect the invasive thoughts and physical symptoms that accompany panic attacks, Taylor finds exposure therapy to be a powerful treatment for panic. In fact, Taylor believes that exposure, or intentionally bringing on a panic attack in a controlled setting (such as the counselor’s office), must necessarily play a large role in overcoming the episodes.

“Patients are not moved by information; they’re moved by what they believe is possible, and they’re moved by new experiences. Just giving them the information [that panic attacks are survivable] is about as good as baptizing a cat,” he says. “If you give them the experience of exposure work in your office, they walk out a changed person. The focus should not be on staying calm but [on knowing] that no matter how hard their heart beats or [how much] they feel a sense of doom, they’re actually safe. It’s just a brain hiccup.”

Inducing a panic attack in the safety of a counselor’s office can prove to clients that what they might experience is uncomfortable but far from fatal, Taylor says. “When a counselor is doing exposure therapy with a patient and inducing panic-like symptoms in the office with them, we as counselors need first to be confident that a panic attack truly is not dangerous to the patient,” he explains. “If they start to panic and then we get scared and try to calm them down, the exposure will fail. We have to be able to stay with it, let the panic attack fully develop and subside on its own, so the patient learns that their fear of having a heart attack, passing out or losing control won’t happen. And unless we can really allow them to go all the way through a panic attack and come out the other side, the exposure just won’t work. They will continue to believe that a panic attack is dangerous and continue to try to suppress and avoid them.”

A good amount of therapeutic work may be required before clients are ready for exposure techniques, Taylor says. Once they are, counselors should begin the experience by asking clients to verbalize the worst thing they can imagine happening to them as the result of a panic attack, he says. Fears that clients typically voice include passing out, vomiting or even having a heart attack.

Taylor says the counselor’s response could be, “OK, are you ready to test that out” in the safety of the counselor’s office?

To induce the elevated heart rate and rapid breathing that accompany panic attacks, the counselor might suggest that the client do jumping jacks, run up and down the stairs or breathe through a straw for an extended period of time. As the panic symptoms swell and peak, the counselor will remain close by to remind the client of the cognitive diffusion and other techniques previously mentioned by Taylor.

Afterward, the counselor can talk about how the things the client feared happening as the result of a panic attack did not actually come to pass. The moment clients realize that they can endure panic attacks without their worst fears materializing is the moment they can begin to overcome the attacks, Taylor says.

Conquering avoidance

Individuals who have experienced panic attacks will sometimes start avoiding situations or places where a prior attack occurred. Often, this includes public places such as shopping malls. If this inclination is left unchecked, it can spiral into the person missing work and social engagements or engaging in other isolating behaviors, Collins says. On top of that, avoidance will serve only to make things worse, she notes.

“That fear of having another panic attack can be crippling,” she says. “One of the fears a lot of people have is having an attack in front of people or being in a place where they can’t escape, such as an airplane or a meeting at work.”

When Collins broaches this subject with clients, she frames it as taking their power back and not letting panic attacks control their lives. “We talk about starting small and [taking] baby steps, especially if they’ve been terrified of a place for a while,” she says.

Counselors can begin by having clients visualize in session the place they have been avoiding. Ask them to describe it and talk about how their body feels as they think about that location, Collins suggests. This process may need to be repeated several times before clients feel comfortable and confident enough to make a plan to actually go to the places they have been avoiding, she adds.

When they do go, make sure the client takes a friend or other trusted person with them for support. Clients should also be directed to stick to the plan they have created and talked through in their counseling sessions, Collins says.

For example, if a client has been avoiding going to a shopping mall out of fear of having a panic attack, a first step in the client’s plan might be simply driving to the mall, parking the car and sitting inside it for five minutes before leaving. The client might even need to repeat that step of the process multiple times, Collins says.

After that, the client can move on to walking through the doors of the mall and then leaving immediately. On the next visit, the client might enter the mall and go into a store, and so on. The idea is to continue going until the client no longer associates that place with feelings of fear.

Counselors can provide a holistic approach to addressing panic attacks that clients might not have experienced previously with medical professionals or other mental health practitioners. Most of all, Collins says, counselors should offer empathy to clients who are confronting such a distressing, overwhelming and, often, seemingly unexplainable experience.

“That validation is the most powerful thing I’ve seen that helps people,” she says. “Clients get better with the relationship, the validation, the compassion. Compassion: That’s the No. 1 thing to remember.”

Zachary Taylor recommends these resources for counselors who want to learn more about the treatment of panic attacks:

DARE: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonagh

Anxious Kids, Anxious Parents: Seven Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Reid Wilson and Lynn Lyons

Interview, “Maximizing Exposure Therapy for Anxiety Disorders” with Michelle Craske, professor of Psychology, Psychiatry and Biobehavioral Sciences and director of the Anxiety and Depression Research Center at the University of California, Los Angeles: sscpweb.org/craske

One of Cyndi Matthews’ most vivid memories of growing up in a fundamentalist Christian church was watching the minister point at her brother’s best friend during a service and say, “You don’t belong here. Get out.” The reason? The boy was gay.

Matthews, a licensed professional counselor supervisor (LPC-S), says that incident was her first glimpse of a pattern of spiritual abuse directed at congregation members who identified as lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ). The animosity that leaders of the church held for LGBTQ members did not fit Matthews’ conception of Christianity. This religious cognitive dissonance would lead her to leave the church and subsequently focus her research and counseling practice on spiritual abuse.

Matthews, a member of the American Counseling Association, sees many LGBTQ clients in her Garland, Texas, private practice who struggle to reconcile their religious beliefs and experiences with their affectional orientation or gender identity. Many of these clients grew up internalizing a message that it wasn’t just their identity or orientation and behaviors that were wrong, but that there was something “wrong” with them as people, she says.

The LGBTQ community has frequently encountered intolerance from religious institutions. Although there are religious traditions that are affirming and open to LGBTQ people, many are not, says Misty Ginicola, lead editor of the book Affirmative Counseling With LGBTQI+ People, published by ACA. Nonaffirming religious groups usually have markedly rigid beliefs — there is wrong and there is right, and nowhere in between, she says. These are the voices that call for anti-LGBTQ legislation under the guise of exercising their religious freedom. As a result, even LGBTQ individuals who do not identify as religious are affected by nonaffirming religious beliefs, points out Ginicola, a member of ACA.

This conflict has produced not just a broader culture clash, but in some religious traditions, a pernicious history of rejection and outright abuse of LGBTQ individuals. Many of Matthews’ LGBTQ clients have been subjected to a wide range of religiously sponsored or endorsed abusive techniques intended to “cure” them. One client — a gay male — was not allowed to cross his legs or wear pink. He was directed to pray anytime he had “gay” thoughts and to replace “gay behavior” with Scripture reading or increased proselytizing. Other of Matthews’ clients were sent to church-sponsored “reparative” retreats where they were prayed over or even subjected to “exorcisms.” Matthews, an assistant professor of counseling at the University of Louisiana Monroe, has also been told about particularly horrific techniques such as forced ice baths and electroconvulsive therapy.

The emotional and even physical abuse that some LGBTQ individuals from strict religious traditions experience is so traumatic that Matthews says all of the survivors she has encountered in her practice were actively suicidal or had been suicidal in the past. At the same time, because clients from strict religious traditions have internalized the idea that what they are told in their churches is God’s word, it is often difficult for them to label their experience as abuse, she says.

Even LGBTQ individuals who break away from their religious traditions so they can fully embrace their affectional or gender orientation have a hard time discounting what they were taught. If someone who identifies as LGBTQ has been told from a young age that they are inherently wrong and immoral, it creates an inner message that lingers, says Ginicola, an LPC in West Haven, Connecticut, whose practice specialties include LGBTQ issues.

Brady Sullivan, a provisionally licensed professional counselor specializing in LGBTQ issues, has worked with clients who believed God hated them. “Every time they engage in sexual or romantic behavior or participate in pride activities, they feel an overwhelming sense of guilt,” he says.

Examining beliefs

Matthews says that, despite their experiences with spiritual abuse, some of her LGBTQ clients still want to find a way to reconnect with religion or at least retain a sense of personal spirituality. Others no longer want anything to do with religion; they come to counseling to untwine the message of being sinful or wrong from their sense of self and sexuality or gender identity.

The therapeutic relationship that is the core of counseling is especially crucial with clients attempting to navigate a conflict between their religious upbringing or current beliefs and their identity as LGBTQ, Matthews says. When people have been taught to seek comfort and strength from a religious tradition that then ends up rejecting them, it feels like a violation of trust, she says. Unfortunately, that sense of rejection can be further compounded when people in the LGBTQ community seek therapy from a practitioner who turns out to be nonaffirming. Matthews always asks clients if they have previously been in counseling and, if so, what that experience was like. This information helps her to address the therapeutic trauma that some LGBTQ clients have experienced.

Matthews screens for spiritual abuse as part of her intake process. She asks clients about their religious background and beliefs and if their experiences are something they would like to address as part of the counseling process. She says that LGBTQ clients from strict or fundamentalist religious backgrounds are highly likely to have experienced spiritual abuse, so the question usually isn’t “if” they will need to work through their experiences, but “when.”

These clients don’t always disclose or even perceive a history of spiritual abuse. However, counselors can look for a number of red flags, Matthews says. These include clients who:

Talk about how they are the cause of their own suffering and need to attend church more and to be more faithful and forgiving to alleviate their suffering.

Display magical thinking attached to “good” and “bad” behavior; they commonly believe that accidents, illnesses and other tragedies are the result of their “sinful” behavior.

Have a difficult time setting boundaries and saying no because of underlying guilt and shame.

Feel powerless to take action or make decisions because they fear repercussions from family members, church members, church leaders or their personal deity.

It is critical that counselors understand their role as helping professionals dedicated to providing a safe and affirming space for all clients, including those who are LGBTQ, says Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counseling program at Southern Connecticut State University. Simply sitting with clients, supporting them in their pain and validating their experiences helps the healing process begin, she says.

Once clients are ready to talk about their conflicted views and feelings related to their sexual or gender identity and their experiences with religion, Matthews helps them explore the harmful beliefs they have been holding on to and works to dispel them. She is careful not to disparage clients’ faith traditions but does encourage them to question whether the condemnation they have been confronted with is actually the voice of God.

Lorrie Byrd Slater, a licensed professional counselor-mental health services provider in Chattanooga, Tennessee, who counsels many survivors of spiritual abuse, uses her knowledge of Christianity to help clients examine their beliefs. She urges clients whose religious communities have condemned or disparaged them to consider what the Scriptures say about the nature of Jesus Christ. She then asks them if their experiences are in line with Christ’s teachings. Slater, an ACA member, also reminds clients that their particular church is just one church out of many; other places of worship hold very different — and affirming — views of LGBTQ individuals.

Ginicola says cognitive behavior therapy is particularly helpful when confronting clients’ internalized beliefs that being LGBTQ is wrong or sinful. She asks clients to consider how those beliefs began and who taught them that they are inherently wrong. Ginicola exposes clients to religious viewpoints that are affirming to LGBTQ individuals through documentaries and bibliotherapy or putting them in touch with affirming pastoral help. She also encourages clients to explore a question for themselves: If God is love, as they have been taught by their faith communities, how could he hate them?

Practicing GRACE

Both Ginicola and Sullivan have found the GRACE model — originally developed by counselor R. Lewis Bozard and pastor Cody J. Sanders — particularly helpful for guiding LGBTQ clients through the resolution of their conflicted religious views. Sullivan, who is practicing part time in addition to earning his doctorate in counselor education at the University of Missouri–Saint Louis, emphasizes that the model is just a guide, not a step-by-step process. For most clients, he uses only a few of the “stages.” The process involves:

Goals: Sullivan, an ACA member, talks to clients about their religious background, asking questions such as what faith tradition they grew up in (Christian, Muslim, Jewish, other) and whether they identify with a particular denomination or sect. He also asks how they feel about what they have experienced, both good and bad.

Ultimately, he wants to find out what clients are hoping to achieve by addressing the conflicts they feel between religious belief and who they are as a person. Sullivan asks: “If you woke up tomorrow and all these issues went away, what would that look like?”

As Sullivan guides clients through their background and goals, he stays alert for reactions, particularly any signs of trauma. If a client seems too upset in a particular session, he will back off and switch to another topic.

Renewal of hope: This stage involves uncovering shame and abuse and working through it, Sullivan says. For instance, some nonaffirming religious leaders individually confront LGBTQ congregants with questions about their affectional orientation or gender identity. These confrontations often take on the tone of an interrogation, culminating witha reminder that “God hates those people.”

Sullivan tells clients that although a particular pastor might think that God hates LGBTQ people, many other religious leaders and faith communities do not hold that belief. If clients are amenable, Sullivan offers to help them make contact with an affirmative pastor to talk about religious views that do not condemn those who are LGBTQ.

Action: This stage represents decision time. Sullivan and the client have talked about the religious conflict for a while, and together they’ve processed the client’s trauma and grief. What does the client want to do now?

Sullivan says his role is to explain clients’ options to them and help them identify what they need to do to move forward. Some clients choose to remain planted in their current religious tradition, unready to move on from a community in which their spiritual roots were cultivated, even if that means continuing to wrestle with painful beliefs and practices. Other clients want to stay under the larger umbrella of their current religious faith but choose to find another church home or denomination that is more affirming of LGBTQ people. Still others decide to make a more drastic change, such as converting to a different faith system entirely. And, finally, Sullivan says, many clients decide that they no longer want anything to do with religion at all.

Connection: For some clients, processing their past experiences and finding a new place to worship isn’t enough, Sullivan says. Instead, they need to examine their personal relationship with God or whatever higher power they relate to. Ultimately, this involves clients identifying what God or that higher power believes about them and how that affects their view of their religion as a whole.

For instance, Sullivan might probe by asking clients what they believe God’s reaction is when they engage in sexual activity with someone of the same sex. He says that most clients are only able to develop the view that although they are sinning, God loves them anyway.

Sullivan does not like to end the GRACE process with this belief still intact. However, he says the pervasive sense of shame that many LGBTQ clients feel often makes it difficult for them to let go of the notion that living a life that embraces their true affectional or gender identity is sinful behavior. “It’s a struggle to get people to realize that God has made them this way and to accept that they are not sinners,” he says.

Empowerment: Sullivan acknowledges that he doesn’t see this stage achieved very often. It takes place only after clients have taken some kind of step such as attending a different church, joining a church-affiliated small group gathering or Bible study, or connecting with a church-sponsored social event, he says. Counselors have an obligation to help clients process these experiences, particularly if they are negative.

“The goal of the empowerment phase is to keep the client traveling down the path toward connection of spiritual and sexual identities, even if they have a negative experience,” Sullivan explains. “This is important because self-confidence and comfort with sexual identity are increased as a result of exploring the intersection between spiritual and sexual identities.”

In reality, Sullivan says, most clients who go through the GRACE model still struggle to reconcile their religion beliefs with being LGBTQ, but they are more at peace with the conflict.

Looking for aff irmative alternatives

One way that counselors can support LGBTQ clients who want to maintain their religious affiliation but feel conflicted is to help them find an affirming congregation, Sullivan says. However, he stresses that counselors must do their due diligence. It isn’t enough to read that the church is part of an affirming denomination or to see that it includes a rainbow flag on its website.

To ensure that he isn’t sending clients into a religious environment that appears affirming but actually isn’t, Sullivan makes a point of calling churches directly. He tells whoever answers the phone that he is a gay man and wants to know the church’s stance on the LGBTQ community. If the person tells him that he is welcome to attend the church and that the church will pray for him and support him in efforts to leave the gay lifestyle, Sullivan thanks them for their honesty but says the church is not for him. Although “welcoming” to LGBTQ people on the surface, churches that hold those types of beliefs do not make it on to Sullivan’s “recommended” list for clients.

Matthews notes that some faith traditions pose a specific and significant challenge to LGBTQ individuals who want to maintain a religious connection. Churches such as the Jehovah’s Witnesses and the Church of Jesus Christ of Latter-day Saints (the Mormon church) embrace particularism — the belief that their particular religious tradition is the only authentic path to God. These paths rest on tenets that are significantly different from what mainstream Christians believe.

For those raised in a church that embraces particularism (and is not affirming of LGBTQ individuals), pursuing their faith by switching denominations is akin to losing their religion entirely, Matthews says. When someone has been told all their life that there is only one path to becoming a Christian and gaining salvation, envisioning another form of faith and worship is almost inconceivable, she explains.

LGBTQ individuals struggling to align their personal and religious identities may look to their families for support. Unfortunately, families are sometimes part of the problem, Matthews says. Many families find it difficult to reconcile their religious beliefs with the reality of their child identifying as LGBTQ.

Matthews has worked with couples from strict religious backgrounds grappling with how to support a child who, according to what the parents hear in church, is living a sinful lifestyle. She provides these parents with psychoeducation by recommending books, giving them information about PFLAG (an advocacy and support organization for the friends, families and allies of those who identify as LGBTQ) and answering their questions, such as whether being LGBTQ is a choice. Matthews might also ask the couple to look for what the Bible actually says about being gay rather than relying solely on what their religious leaders say.

Counselors must also consider that particularly for LGBTQ people of color (POC) or those of low socioeconomic status (SES), leaving their religion behind may also mean losing their community, Ginicola says. “If you are a POC or have low SES, religion is not just a place you go sometimes; it could be a lifeline,” she says.

Losing a whole community can be devastating for anyone, but particularly for someone who has multiple marginalized identities, Ginicola continues. She gives the hypothetical example of a gay black man who, by coming out, loses his church. But when he turns to the LGBTQ community, he may encounter sporadic instances of racism. As a result, he ends up feeling like he is not fully accepted — and, thus, can never feel totally comfortable — anywhere.

Counselors need to let those with marginalized multiple identities know that counseling is one place where they can be fully themselves, Ginicola says. Counseling can encompass all of who these clients are — black, Christian, gay — without judging. Many people seem to think that they can identify either as LGBTQ or religious, but not both, Ginicola notes. She believes the idea that these two identities can’t coexist is harmful because faith — believing in something greater than ourselves, even if it isn’t a deity — is an integral part of life.

Given their negative experiences, some LGBTQ people lose all desire to return to organized religion. Regardless, spirituality can remain a significant part of who they are as people, says Slater, an assistant professor of counseling and associate dean of students at Richmont Graduate University. Spirituality is not the same as religion. In fact, an individual’s spirituality may not even encompass God. Spirituality is simply something that is bigger than us and that provides people with a sense of purpose, Slater says. For some people, that sense of spirituality and meaning can derive from nature, philosophy, personal ideology, science or even the belief in human rights for all, she explains.

Even when LGBTQ clients ultimately decide that they no longer identify with their past religious faith, Matthews tells them that it is possible to hold on to certain positive aspects and values of their religious upbringing that still resonate with them, such as practicing generosity and gratitude and loving others. Or, if these individuals previously enjoyed reading the Bible as literature, she might suggest that they explore other religious or spiritual texts outside of their faith tradition. If the ritual of prayer once provided clients with a sense of peace, she might encourage them to replace that experience with something nonreligious, such as a meditation practice.

Wearing blinders

Counselors who identify as religious know that imposing their values on clients is unethical, and most counseling professionals work hard to bracket their beliefs. Laura Boyd Farmer, an assistant professor of counselor education at Virginia Tech, has published numerous research studies on LGBTQ issues. She recently completed a research study that has not yet been published but that was presented at the 2017 ACA Conference & Expo in San Francisco. The study consisted of a survey that asked 455 mental health and school counselors how they thought their religious beliefs affected their work with LGBTQ clients.

Some respondents said that because their religious traditions were based on acceptance and the idea that Jesus loves everyone, their beliefs had a positive effect, helping them to provide LGBTQ-affirmative counseling. Other participants said their work was in line with their religious tradition, which calls on believers not to judge. Some counselors said that they disagreed with the LGBTQ “lifestyle” but chose not to judge. Others disclosed that their religious beliefs pose a conflict with which they struggle — striving to practice ethically despite their nonacceptance of LGBTQ individuals. Some respondents said that they agreed with the statement “love the sinner, hate the sin” and that this belief did not negatively affect their counseling of LGBTQ clients.

When counselors refuse to counsel LGBTQ clients because their religious beliefs tell them that doing so is wrong, that represents an obvious violation of the ACA Code of Ethics. But where things get tricky is with counselors who take a low-profile nonaffirming stance, says Farmer, an LPC who provides pro bono counseling for LGBTQ individuals in the Roanoke, Virginia, area. These are the counselors who say that they don’t agree with the “lifestyle” but wouldn’t refuse to counsel LGBTQ clients. These practitioners may think that no matter what their beliefs are, they can still maintain unconditional positive regard for their clients, but they might be operating with a big blind spot, Farmer contends.

To illustrate her point, she describes a recent casual conversation she had with a practicing counselor. This person talked about working with gay clients despite believing that being LGBTQ is a sin. The counselor said that they just tried not to judge. Farmer, an ACA member, asked how the practitioner was able to do that. Their response: “To be honest, it doesn’t come up.”

In providing counseling yet not fully accepting LGBTQ clients, this counselor was attempting to manage conflicts with their personal religious beliefs by avoiding pertinent topics. For example, Farmer says the practitioner was working with a gay youth struggling with depression, yet the challenges of identifying as LGBTQ “never came up.” Farmer says this makes her wonder how many other professional counselors are walking around wearing blinders.

Counselors like the one in Farmer’s story are not fully owning — or understanding — their bias, Ginicola says. A bias isn’t just, “I hate these people,” she explains. It’s also that working with someone who is LGBTQ doesn’t feel “right” and the counselor isn’t comfortable with it. By not confronting the discomfort, counselors are much more likely to miss signs (even if unintentionally), miscommunicate and project their worldview on the client rather than identifying the real issues, Ginicola asserts.

Disaffirming counselors resent that ACA’s ethics code requires them not just to set aside their personal beliefs to work with LGBTQ clients but to actually be advocates for them, Ginicola says. These counselors don’t view the experiences of LGBTQ clients as valid, she adds, and it is impossible to work effectively with clients unless you intrinsically embrace their value.

****

Additional resources

To learn more about the importance of exploring aspects of religion and spirituality in clients’ lives, take advantage of the following select resources offered by the American Counseling Association:

Having kids and young adults train rescue dogs isn’t technically animal assisted therapy, but for the kids—and dogs—involved in the Teacher’s Pet program, the result has definitely been therapeutic.

The youth —with the help of professional animal trainers— use positive reward-based training to increase local rescue dogs’ chances of being adopted. In return, working with the dogs helps the students develop patience, empathy, perseverance and hope, says Amy Johnson, the creator and executive director of Teacher’s Pet, a Detroit-area non-profit program.

The idea for the program was born when Johnson, a former public school teacher, was working as a dog training instructor at the Michigan Humane Society. Johnson, an American Counseling Association member, wasn’t sure what the training would look like at first — she simply knew

Images courtesy of Teacher’s Pet. Identifying features of (human) participants have been blurred for confidentiality.

she wanted an intervention that would help both kids and dogs. Johnson contacted every group she could find in the United States and Canada that worked with both youth and dogs to learn more about how their programs worked. Her intent was to work with kids who — like their canine counterparts — were behaviorally challenged and often unwanted. So, not only did Johnson contact school counselors and psychologists for their input, she decided to become a professional counselor herself.

The end result was a program that is 10 weeks long and meets twice a week for two hours. Teacher’s Pet currently works with teens from an alternative high school and three detention facilities and young adults, aged 18-24 at a homeless shelter, says Johnson, a licensed professional counselor. At each facility (except for the homeless shelter), the training takes place on site. Participants from the homeless shelter are brought to an animal shelter to complete the program.

The program’s group facilitators are all professional trainers and they choose only dogs with good temperaments to participate, says Johnson, who is also the special projects coordinator and director of the online animal assisted therapy certificate program at Oakland University in southeast Michigan. Before the participants begin working with the dogs, the facilitators give them some safety training.

“We spend the first day going over body language and stress signals,” Johnson says. “They meet the dogs on day two, after one more hour of dog body language education.”

Other safety measures include limiting the number of dogs — five or six per class of 10 students — and keeping the dogs on long tethers placed 10 feet apart so that they can’t interact with each other, she says. There are also always at least four trainers in the room and the dogs are closely monitored. If a dog gets overexcited, is struggling to get off the tether or barking at another dog, a trainer will remove it from the room, Johnson says.

At the beginning of each session, the lead facilitator goes over the goals for the session, such as teaching the commands “sit,” “stay” or “down,” learning to walk on a leash or not jump for the food bowl. The individual trainers explain how to teach the commands and let the teens or young adults do the actual training as they supervise. The dogs are never forced to participate—if an individual dog is nervous or reluctant, the goal for the day is to establish trust and confidence, she says.

Johnson says that sometimes dogs that come off the streets have specific problems like trembling when people walk by. In that case, the students will sit with the dog until it becomes more comfortable and then start with small steps like going for a brief walk outside.

As participants are teaching the dogs new behavior, often their own behavior changes, she says.

In particular, a lot of the teens and young adults who participate have poor communication skills, Johnson says. For instance, some are so shy that they don’t project their voices and the dogs don’t respond to their commands. The participants have to learn to speak firmly and assertively, and to demonstrate a sense of command by standing up straight. One boy told Johnson that he decided to test the tone of voice and body language he used with the dogs on his peers to see what would happen. Imitating the behavior he used with the dogs gave the boy more confidence and he found it easier to interact with his peers, she says.

Johnson describes another boy who was very angry, had little patience and low impulse control. He had a soft heart and would choose dogs that were struggling, which told Johnson that he was projecting his anger.

“Inside he was like the dogs [scared],” she says. So the trainers paired the boy with a dog that was afraid of men. His job was to make the dog like him, Johnson explains. The boy had to be patient and sit with the dog. As the dog got calmer and more confident, the boy would gently encourage it to move closer and closer. By the end of the program, the dog was joyfully playing with boy.

Johnson says that the program facilitators coordinate with the participants’ counselors when possible, so that if they are struggling with particular problems — such as patience or impulse control — training sessions can include activities that help address those difficulties.

The teens and young adults also learn from each other. The first hour of each session is devoted to training and the second to journaling and “debriefing” — talking as a group about what worked and what didn’t.

Johnson believes that even just the oxytocin release that comes from spending time with the dogs is highly beneficial. The program participants are often deprived of loving human touch and the dogs will lick and hug and make them laugh — reducing their anger and anxiety.

As the program draws to end, saying goodbye isn’t easy, but that in itself can be a lesson learned, Johnson says. The students start to detach from the dogs a little bit, and they’ll talk about how that is a normal part of processing grief and loss, she says. The kids also write letters to potential adopters touting the dogs’ accomplishments.

When the program is over, the teens and young adults say goodbye to the dogs and learn that they can say goodbye and not have it be the end of the world, says Johnson. The participants also get lots of pictures of themselves with the dogs and a certificate for the wall. Many former students have told Johnson that they keep a picture of themselves and the dog they trained on their dressers.

“I had a youth email me seven years later and ask me for another copy of his certificate because his was in a storage unit that was auctioned off,” she says.

Many graduates want to volunteer with Teacher’s Pet for adoption and other events, Johnson says. The organization also remains a resource for the students — they can get letters of recommendation or basic things like clothes for school or school supplies if needed.

Johnson says that Teacher’s Pet is also currently working with the American Society for the Prevention of Cruelty to Animals (ASPCA) on a longitudinal study to determine if the program produces behavioral changes in the kids, and if so, for how long.

A few years ago, while teaching a course in family therapy, a particularly bright and insightful student named Maria lingered after class one day and asked, “Isn’t differentiation of self similar to mindfulness?” I hadn’t quite thought of it like that before, but it certainly seemed plausible. “Let’s set aside some time to talk,” I suggested. With that single question began many months of conversations.

In 2015, a continuation of those hours of exploration transformed into an “anti-presentation” that was awarded “Best of Show” at the Louisiana Counseling Association Annual Conference. The examination continued the following spring at the American Counseling Association Conference & Expo in Montréal. In the end, it was inquiry rather than answers that animated our informal lyceum. Quest and question are born of a common root. And teaching is thin soup if only the student grows. The current work is an attempt to extend the spirit and tone of those many fruitful hours of meeting.

Attempting to define differentiation

Differentiation of self (DoS), since first being introduced by Murray Bowen in the early years of the family therapy movement, has remained a lofty, elusive and often misunderstood concept. As Bowen’s colleague, Michael Kerr, pointed out, differentiation contains so many unique conceptual facets that it defies simple definition.

Bowen himself, persistently mystified by the consistent misinterpretation of differentiation, noted late in his life in one of his more cantankerous moments that he wished he’d never “discovered” it in the first place. Anthropologist Gregory Bateson once said of Charles Darwin that he didn’t discover evolution, he made it up. The same may be said of DoS. Viewed through this lens, DoS becomes a story (the point of which is to communicate its creator’s intent) steeped in a deep faith in science and the relatively recent emergence of the Western nuclear family.

If we are to accept the premise that differentiation does indeed defy simple definition, or at the very least is so subtle and nuanced that it is open to numerous interpretations, the initial question that emerges is: What in the world are we actually talking about when we talk about differentiation?

Michael Cowen, one of my colleagues at Loyola University New Orleans, provides a useful foundation from which to launch this conceptual ship with his interpretation of differentiation as “the capacity to be aware of one’s own unique pattern of feeling, valuing and thinking, and to decide and act in ways that remain faithful to that awareness.” Cowen’s definition shifts the focus of differentiation away from some thing that one is or has or even does, toward a description of understanding and action. It is a process that, at its core, allows individuals to make distinctions between thoughts and feelings and to remain calm in highly emotional situations. It is the ability to be both a part of and apart from significant relationships, and it places a high premium on the ability to behave rationally. It is not, however, a call for a Spock-like hyper-rationality nor a ringing endorsement of the ruggedly individualistic American mythology.

For the sake of moving forward with consensus, nebulous as it may be, I (Kevin) am inclined to give Bowen the final say in the construction of a working definition of differentiation as “a way of thinking that translates into a way of being.” So the story goes.

If that description of differentiation is to be accepted, the question then becomes, how is one to cultivate such “a way of thinking?” And who might act as a reliable translator? This is the point at which the teaching of the Buddha, in general, and mindfulness, specifically, can offer a helpful perspective from which to view perceptions and human experience.

At first glance, Bowen and Buddha may seem to be a strange pairing. After all, Bowen’s search for understanding led him back to the tumult of his family of origin, whereas Buddha left home seeking transcendence and never returned. Logistically, Buddha’s eightfold path provides a different road map toward liberation and understanding than does Bowen’s eight interlocking theoretical concepts. But the wisdom gained beneath the Bodhi tree may not be as divergent from the family tree as one might think. When differentiation is examined through the prism of mindfulness, significant conceptual convergences begin to emerge. The potential implications for personal growth, insight and clinical practice merit a pause, perhaps a deep breath, and further contemplation.

Mindfulness

Mindfulness is essentially the act of being present. Anchored in continuous awareness of each emerging moment, it is the cultivation of a calm, dispassionate state in which experience can be examined with acceptance and nonjudgment. Mindfulness, not unlike DoS, is a process that provides the possibility of escaping the trappings of emotional reactivity.

In an excellent article examining mindfulness (“Mindfulness: A Proposed Operational Definition” in the September 2004 issue of Clinical Psychology: Science and Practice), a group of Canadian academics, led by Scott R. Bishop, pointed out that the insight that emerges through disciplined contemplative practice creates an open “space between one’s perception and response, ultimately making it possible to respond and interact more reflectively (as opposed to reflexively).” Rather than becoming tangled up in “ruminative, elaborative thought streams about one’s experience and its origins, implications and associations, mindfulness involves a direct experience of events in the mind and body,” wrote Bishop and his colleagues

In other words, we are able to stay tethered in the present, experiencing our life with courage and composure as it actually unfolds in our midst. In this awakened state, our mind is freed from anger, attachment to desire and misperception. Providing an alternative to being swept away in a flood of emotionality and elaborate misinterpretation, we are able to resist the urge to flee into ideations of the imagined future clouded by the residue of the past, or compulsively bend reality to meet idiosyncratic needs.

Mindfulness is the antidote to fear, confusion and anxiety. It is a practice and process that tethers us to the immediacy of our lives with the insight to see “relationships between thoughts, feelings and actions and to discern the meaning and causes of experience and behavior” (as described in “Mindfulness: A Proposed Operational Definition”). Essentially, mindfulness cultivates the ability to interact rather than react.

The greatest hurdle in defining a self or sustaining mindful attention is emotional reactivity. When emotions escalate beyond a critical threshold, a state of mind emerges in which rational thinking evaporates and agitation hijacks the cognitive process. It is impossible to differentiate in such an agitated state. We become prisoners to automatic emotional responses saturated in fear.

Buddha referred to this reactive state as “monkey mind,” in which fear becomes much like a loud, drunken monkey frantically screeching the alarm bells of danger in our brains. The ability to quickly regain composure and quiet the monkey mind is the cornerstone of both differentiation and mindfulness.

The quiet mind is fertile ground for exploring what Buddha called “store consciousness.” Long before Sigmund Freud proposed his theory of the unconscious (again, see Bateson above) or Bowen began his examination of psychobiological cognitive-emotional processes, Buddha was wandering about preaching the Dharma, teaching practices aimed at liberating people from misperception and attachment to mental formations that seemed to be just beyond the reach of everyday awareness.

Vietnamese Buddhist monk Thich Nhat Hanh writes in the introduction of Cultivating the Mind of Love: “In our store consciousness are buried all the seeds, representing everything we have ever done, experienced or perceived. When a seed is watered, it manifests in our mind consciousness. … The work of meditation is to cultivate the garden of our store consciousness.”

Getting back into harmony with our lives

Whatever we “attend” to will grow. And what we don’t attend to will tend to grow out of control without insight into content and coping strategies buried deep in our store consciousness. For multigenerational family systems theory, the seeds in the soil are the early experiences in the family of origin. Differentiation allows for a bit of psychic “weeding” to occur so that intimacy and integrity may grow.

Buddha, too, was attuned to the influence that family members have on one another. Perhaps more poetic, but no less prophetic, a Buddhist teaching examines the importance of the emotional climate of filial bonds, invoking the image of the garden again: “A family is a place where minds come in contact with one another. If these minds love one another, the home will be as beautiful as a flower garden. But if these minds get out of harmony with one another, it is like a storm that plays havoc with the garden.”

It is precisely in those moments when one finds oneself in the “I” of the storm where mindful intention allows the well-differentiated self to stay calm and sift through frenetic cognition that often causes impairment in our lives. The ability to sit in the midst of the tempest and remain present, self-aware and in close emotional contact with others is the essence of what Soto Zen monk Shunryu Suzuki calls “imperturbable composure.”

The well-differentiated self exhibits radical acceptance to what Jon Kabat-Zinn calls the “full catastrophe of living.” In this way, we remain open and curious to the actual events of our lives as they unfold, freeing ourselves from endless cycles of suffering and automatic reactivity. Whether we call this mindfulness or differentiation becomes an exercise in semantics.

Through work and practice, we become available to the full reality of our lives, with the insight and courage to quietly slip through the cracks of our conditioning and allow our ego-cramped consciousness to release its grip on our battered psyche. Quite simply, DoS and mindfulness bring us back into harmony with our lives.

For Buddha, the ultimate act of enlightenment is to wake up. The Dharma teaches that it is possible for any of us to awaken at any moment in our lives. Much like achieving a fully mindful present state, people often find embarking on the path of defining a self to be a daunting task.

Bowen was clear and consistent in his insistence that the fully differentiated self is a theoretical concept that is practically unattainable. It is a guiding light rather than prescription. However, with much work and practice, it is possible to increase one’s level of differentiation. Bowen pointed out that if we can “control the anxiety and the reactiveness to anxiety, the functional level will improve.” The task at hand becomes “getting beyond anger and blaming to a level of objectivity that is far more than an intellectual activity. … The overall goal is to be constantly in contact” with emotional issues involving ourselves and others.

A common thread

Although Bowen and Buddha’s conceptualization of the “self” superficially seems to be the point at which the Venn in the Zen between DoS and mindfulness begins to diverge, it is through interdependence that the deepest synthesis actually occurs. Whether one adopts a scientific or a spiritual perspective, the influence that each of us has upon the other is the thread that ties mindfulness and differentiation together.

Bowen was certain that the self exists. Buddha sent his disciples out into the world in search of the self and sat patiently waiting for the report back. Ralph Waldo Emerson, with his ever-present, transcendental wisdom, offered this: “All that is said of the wise man by Stoic or Oriental or modern essayist … describes his unattained but attainable self.”

Both Buddha’s and Bowen’s philosophical views were undergirded by a belief in the profound effect that each of us has upon one another. Bowen believed that successfully differentiating oneself within the system could have significant influence on all others in that system. He noted that if one is able to successfully define a solid sense of self and defend against requests from others to change back to old ways of being, then the entire system can catapult forward into higher levels of functioning.

The Dharma teaches that when one is awakened with compassion and wisdom, all are touched by the light. In Cultivating the Mind of Love, Hanh examines Buddha’s teachings, exploring the ways in which the Dharma opens each of us to the possibility of deeper understanding and more intimate connection. In his introduction, Hanh invites us to become fully present, and “the rain of the Dharma will water the deepest seeds of your store consciousness. If the seed of understanding is watered … the fruits of love and understanding will grow.”

Examining the teaching of interbeing and the delusion of separateness falsely constructed in the mind, Hanh concludes: “We must vow to practice for everyone, not just for ourselves. … Because of our ignorance and habit energies, we usually perceive things incorrectly. We are caught in our mental categories, especially our notions of self, person, living being and life span. We discriminate between self and nonself. … When we see things this way, our behavior will be based on wrong perceptions. Our mind is like a sword cutting reality into pieces, and then we act as though each piece of reality is independent from other pieces. If we look deeply, we will remove these barriers between our mental categories and see the one in the many and the many in the one, which is the true nature of interbeing. … Everything is touching everything else. … To bring relief to one person is to bring relief to everyone, including ourselves. This insight brings about the kinds of actions that are truly helpful.”

These are hopeful thoughts for troubled times. What is called for in this moment, if one is to view differentiation through the lens of mindfulness, is a “way of thinking that translates into a way of being in the world” that accurately perceives the deep connection that we have with the world surrounding us and the profound effect that each of us has upon one another. So the story goes.

Compassionate listening

Counseling is a reciprocal process of story and interpretation. As a conversational intervention, much attention has been given to the narrative telling of the tale — the “talk” in talk therapy. Often lost in the reciprocity is the transformative power of listening. As Hanh points out, when we listen to another deeply and compassionately, we help that person to suffer less. “One hour like that can bring transformation and healing,” he teaches.

If listening in this way does indeed, as we believe, lead to the alleviation of suffering, the question becomes, how does one engage in the process of compassionate listening?

The calm that accompanies the differentiated self, and a mindful stance tethered in the present, provide a helpful perspective from which to enter into another’s story. It allows one to avoid judgment without abandoning discernment and concern. This way of being allows the counselor to bear witness to the tumultuous content of clients’ troubled narratives without becoming overwhelmed. We can tolerate intense emotion without needing to flee for safety and care without getting carried away.

Deep listening contains the seeds of empathy. The calm that accompanies a well-differentiated presence opens up the space to create the distance necessary to examine problem-saturated narratives. The practice of active listening artfully folds the story continuously back upon itself, returning the client to present-moment awareness. The acceptance that accompanies awareness invites the client to slow down, resist the impulse to avoid the suffering and instead examine the story with compassion. The wisdom to accept that which is beyond our control paradoxically generates the flexibility necessary for transformation to occur.

Pragmatically speaking, compassionate listening is rooted in language. To listen in this manner, it is essential to remain firmly planted in the present, gathering content without getting lost in the labyrinth of past suffering or anxious projections of the future. When listening to stories of suffering, it can be easy to lose sight of the fact that the actual experience is the retelling of the tale here and now, not what occurred there and then. It is imperative to honor our clients’ suffering while also uncovering their strength.

The task is to attend to the content of the client’s story while staying deeply connected to the person. Listening in this way allows us to wonder what the client is trying to communicate about his or her struggle through the story. What meaning is seeking to be understood? What are the relational and emotional elements recurring in the client’s words? Compassionate listening is the conduit into the deepest sense of clients’ experiences. It asks, how can we be present to the struggle and help our clients confront the frustrating and most frightening moments of their lives?

At its core, compassionate listening holds the therapeutic space. It widens the client’s interpretation just a bit. It uses the client’s language, symbols and metaphors. It sees as well as hears, deconstructing the story, searching the margins for what has been edited out, pulling the thread of seemingly disjointed pieces and reflecting it back in recognizable form. This way of listening is ultimately a path toward healing that allows for safe passage through suffering. As American Buddhist nun Pema Chödrön points out, mindfulness allows us to choose an alternative course for our lives. A process such as DoS requires us to first notice the true nature of our experience, then disrupt our habitual patterns and do things differently and, finally, practice again and again, one moment at a time.

A client suffers and a change is necessary. The struggle often comes with not knowing how to manifest a healthy change. The client has likely been avoiding, wrestling with and running away from anxiety for years, creating deeply ingrained habits. In the space created by deep listening, the client can experience something different. Clients may be able to look at their anxiety for the first time with compassion and understanding. The paradox is that once they are able to sit with their struggle instead of avoiding it, anxiety loosens its grip on their lives.

DoS, viewed through the lens of mindfulness, creates the clarity and compassion for transformation to occur. Mindfulness aids in the process by creating awareness of our mind-body interaction so that we can become more skillful in our interpersonal, and intrapersonal, relationship(s).

Just as the counseling process makes space for emotions, thoughts, ideas and stories in session, mindfulness creates a similar space for our internal experience to occur. This is the “deep listening” to our own process. Mindful awareness allows for attunement, not only with our clients but with ourselves. It creates systemic and intrapsychic awareness to the ways that we get hooked into metanarratives and mental confines. Emotions no longer run amok, and we are available to be in relationship with others. As clinicians, we must first listen deeply to the mystery and history of our own stories before making contact with someone else’s.

The Beat Zen of Richard Brautigan leads us to a quiet place to begin in his poem “Karma Repair Kit: Items 1-4”:

1. Get enough food to eat,/ and eat it.

2. Find a place to sleep where it is quiet,/ and sleep there.

3. Reduce intellectual and emotional noise/ until you arrive at the silence of yourself,/ and listen to it.

4. ???

****

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Kevin Foose is an assistant professor in the Department of Counseling at Loyola University New Orleans. He maintains a private practice that focuses on couples and adult individuals. Contact him at kjfoose@loyno.edu.

Maria Cicio is a graduate of the Loyola University New Orleans master’s in counseling program, class of 2015. A licensed professional counselor, she is currently working in community mental health in rural Oklahoma.

In the opening chapter of the sixth edition of Counseling and Psychotherapy: Theories and Interventions (published by the American Counseling Association), David Capuzzi, Mark Stauffer and Douglas Gross make the case that the helping relationship is central to all effective counseling. Not many counselors would argue with this idea. Nevertheless, many counseling practitioners still feel pressure to implement empirically supported or evidence-based mental health treatments. Consider this case:

Darrell is a 50-year-old Native American. He identifies as a male heterosexual. In his first counseling session, he talks about feeling “bad and sad” for the past six months and meets diagnostic criteria for a depressive disorder. Darrell’s counselor, Sharice, is trained in a manualized, empirically supported cognitive-behavioral model for treating depression. However, as a professional counselor, she values collaborative counseling relationships over manualized approaches. She especially emphasizes relational connections during initial sessions with clients who are culturally different from her.

The question is, how can Sharice be relationally oriented and still practice evidence-based counseling? The answer: She can use evidence-based relationship factors early and throughout the counseling process.

Evidence-based relationship factors

Back in 1957, Carl Rogers wrote that “a certain type of relationship between psychotherapist and client” was “necessary and sufficient” to produce positive change. In contrast, if you immerse yourself in contemporary research on counseling and psychotherapy, you might conclude that relationship factors in counseling are passé and that, instead, cutting-edge (and ethical) practitioners must use empirically supported treatments. But you would be wrong.

Most reasonable people recognize that both relationship factors and techniques contribute to positive outcomes. However, it is also true that relationship factors in and of themselves have strong empirical support. More than 60 years of scientific evidence supports Rogerian core conditions of congruence, unconditional positive regard and empathic understanding. In fact, counseling relationship factors are just as scientifically potent (and maybe more so) as so-called empirically supported treatments.

Newer terminology for acknowledging the research base for therapeutic relationships has been coming for about 15 years. In 2001, a task force from Division 29 (Society for the Advancement of Psychotherapy) of the American Psychological Association coined the phrase “empirically supported therapy relationships.” The task force’s purpose was to place therapeutic relationships on equal footing with empirically supported treatments. Despite those efforts, many (and perhaps most) psychologists value technical procedures (for example, cognitive behavior therapy) over relational factors. In contrast, because of counseling’s emphasis on therapeutic relationships, in some ways, empirically supported therapy relationships are much more relevant to professional counselors.

In this article, we use the broader phrasing of “evidence-based relationship factors” (EBRFs) to represent ways in which professional counselors can integrate research-based relationship knowledge into counseling practice. But what is an EBRF, and how can counseling practitioners implement them in ways that are more specific than simply saying, “I value the therapeutic relationship?”

EBRFs include the three Rogerian core conditions and other purposefully formed and implemented relational dimensions. Below, we provide concrete examples of 12 EBRFs that are empirically linked to positive counseling and psychotherapy outcomes. For each EBRF, we use the case of Sharice and Darrell to illustrate how Sharice can work relationally with Darrell and still engage in evidence-based practice.

Evidence-based attitudes and behaviors

Rogerian core conditions of congruence, unconditional positive regard and empathic understanding are foundational EBRFs. Although Rogers described them as attitudes, they also have behavioral dimensions. Additionally, counselors bring other relational factors into the room, such as role induction, cultural humility and scientific mindedness. Together, these EBRFs create a welcoming, safe and transparent environment that fosters therapeutic relationship development. Simultaneously, counselors are responsible for managing their countertransference throughout the relationship development process.

Congruence

Congruence implies counselor self-awareness and involves holding an attitude that values authenticity. Clients typically experience counselor congruence as the unfolding of a genuine relationship with their counselor. Genuineness involves counselors striving to be mindfully open and honest in their interactions with clients. This usually, but not always, involves self-disclosure, immediacy and offering feedback.

****

Sharice displays congruence in several ways. First, she presents Darrell with an informed consent document that is written in her unique voice and that includes information on how she works with clients in counseling. She also greets Darrell with clear interest in learning more about who he is and what he wants. To focus on him, she might sit and emotionally center herself before going to meet him in the waiting room.

During the session, when Darrell talks about details of his professional work, Sharice openly expresses curiosity, “Oh, you know, I’m not sure what you mean by that. Could you tell me more so I can better understand what you’re experiencing in the workplace?” After Darrell shares details, she says, “Thank you. That helped me understand what you’re up against
at work.”

Role induction

Role induction is the process through which counselors educate clients about their role in counseling. Role induction is necessary because clients do not naturally know what they should talk about and because they may have inaccurate expectations about what counseling involves. When it goes well, role induction is interactive, and counselors simultaneously exhibit Rogerian core conditions (“I hope you’ll always feel free to ask me anything you want about counseling and how we’re working together”). Role induction begins with the written informed consent form.

****

Sharice includes in her informed consent document what her clients can expect in counseling. She also explores these topics with Darrell in their first session.

Sharice: I’d like to share a bit with you about what we’ll be doing in this first session. To start, I want to hear about what’s been happening in your life that brings you to counseling now. As you talk, I’ll ask a few questions and try to get to know you and your situation better. We’ll talk about what’s happening now in your life and, if it’s relevant, we’ll talk some about your past. Then, toward the end of our session, I’ll share with you some ideas on how we can work together, and we’ll start to make a counseling plan together. Please ask me questions whenever you like.

Unconditional positive regard

Unconditional positive regard involves the warm acceptance of clients. Rogers himself noted that unconditional positive regard was an “unfortunate” term because no counselor can constantly experience unconditional positive regard for clients. However, to the extent that it can be accomplished, unconditional positive regard involves acceptance of the client’s self-reported experiences, attitudes, beliefs and emotions. Unconditional positive regard allows clients to feel the safety and trust needed to explore their self-doubts, insecurities and weaknesses.

****

Throughout their time together, Sharice shows Darrell unconditional positive regard by listening to his experiences, attitudes, beliefs and emotions without showing judgment. She’s open to whatever he brings into the session and encourages him when they encounter subjects he finds difficult to explore. She not only listens nondirectively but also asks questions such as, “What’s your best explanation for why you’re feeling down now?” and “What are you thinking right now?” These questions show acceptance by supporting and exploring Darrell’s self-evaluation rather than focusing on Sharice’s judgments.

Empathic understanding

Empathy is one of the strongest predictors of positive counseling outcomes. However, there is one interesting caveat. It doesn’t matter if counselors view themselves as empathic; what matters is for clients to view their counselors as empathic.

Although measuring empathic responding is challenging, there is consensus that using reflections of feeling and engaging in limited self-disclosure are effective strategies. Also, there is evidence from neuroscience research that resonating with or feeling some of what clients are feeling is part of an empathic response.

****

When responding to Darrell, Sharice uses her facial expressions, posture, voice tone and verbal reflections in an effort to comprehend Darrell’s unique thoughts, feelings and impulses. She expresses empathy as he talks about work stress.

Darrell: I feel pressure coming at me from everywhere. Deadlines that need to be met, clients to make happy, bills that need to be paid, and I need to maintain this image in the community, you know?

Sharice: That sounds stressful. You have people counting on you, and it feels overwhelming.

Following an initial reflection of feeling, Sharice uses what Rogers referred to as “walking within” to emotionally connect on a deeper level.

Darrell: It’s starting to get to me in ways stress hasn’t before. Like, I can’t sleep, it’s harder to focus, and I feel like I’m going to burn out soon.

Sharice: It’s like you’re saying, “I don’t know how much more of this I can take, and I don’t know what to do.” Do I have that right?

Later, Sharice uses a reflective self-disclosure (which combines congruence with empathic understanding) in an effort to deepen her empathic resonance.

Sharice: As I listen to you, Darrell, and as I try to put myself in your shoes, I feel physically anxious. It’s almost like this pressure and pace make me feel out of breath. Is that some of what it feels like for you?

Just like Carl Rogers would do, Sharice intermittently checks in with Darrell on the accuracy of her reflections (“Do I have that right?”). Additionally, if Darrell indicates that Sharice is not hearing him accurately, she uses paraphrasing to refine her reflection and sometimes apologizes while correcting herself.

Cultural humility

Cultural humility is an overarching multicultural orientation or perspective that includes three dimensions:

1) An other-orientation instead of a self-orientation

2) Respect for client values and ways of being

3) An attitude of equality, not superiority

Like the Rogerian core conditions, cultural humility is an attitude that counselors adopt before entering the counseling office, but there are also behavioral manifestations of cultural humility.

****

In their first session, Sharice creates a space for Darrell to speak about what his culture means to him. She notes that even though they come from different cultures, understanding his culture is important to her.

Sharice: Thank you for filling out the intake form, Darrell. I know it can be daunting with all the personal information we ask for. I see that you are Native American. I’m a mix of German and Swiss and grew up outside of Denver. What this means to me is that I’ll be trying my best to understand your life experiences. If at any point you think I’m not getting your perspective, I hope you’ll tell me. Sound OK? (Darrell nods.) Thanks. Also, whenever you’d like, I’d be interested in hearing more about your culture and how it informs your way of being in the world.

Scientific mindedness

Scientific mindedness is a concept and skill originally described by Stanley Sue. It refers to the process of counselors forming and testing hypotheses about clients rather than coming to premature, and potentially faulty, conclusions.

****

As Sharice gets to know Darrell and the issues that brought him to her office, she uses scientific mindedness to hypothesize how culture may (or may not) be a salient factor in his experience of stress in the workplace. When he talks about “immense pressures” that he puts on himself, she’s reminded of how some individuals from minority groups can feel added stress because they view themselves as representing their entire minority community. Sharice keeps this hypothesis in the back of her mind and, eventually, when the time seems right, uses a reflective listening response to test her hypothesis.

Sharice: When you talk about the pressure you put on yourself to perform, it sounds like you’re performing not only for yourself but also for others.

Darrell: Absolutely. I can’t help but worry because my family depends on me to generate income. (Somewhat to Sharice’s surprise, Darrell doesn’t identify his tribe or the reservation community as an additional source of pressure to perform, so she explores the issue more directly.)

Sharice: I’ve read and heard from some of my other Native American clients and students that it’s possible to feel added stress because they might view themselves as representing their tribe or other Native American people. Is that true for you?

Darrell: I always tell myself that that’s not an issue for me. But if I’m totally honest with myself and with you, I’d have to say that being an Indian man in an intense business environment makes for more stress. In some ways, I think it has less to do with representing my people and more to do with how I think my colleagues — and even my friends at work — somehow expect me to be less competent. I don’t know exactly what they think of me, but I feel I need to work twice as hard to earn and keep their respect. (After listening to Darrell’s disclosure, Sharice updates her hypothesis about how race and culture might be adding to his stress at work.)

Sharice: So, it’s not so much that you feel like a representative for your people. It’s more that you’re thinking and feeling that you should do double the work to prove yourself to your colleagues. I can imagine how feeling discounted compounds the everyday workplace stress you feel.

Managing countertransference

Countertransference is unavoidable. Countertransference includes the counselor’s emotional reactions to any or all clinically relevant client material (transference, client personality, content presented by the client, client appearance and so on). These reactions may be related to the counselor’s unresolved personal conflicts or the client’s interpersonal behaviors. Countertransference can be a hindrance or a potential benefit to the therapeutic process; it can distort your perceptions of your client, but it can also inform your relationship with the client.

****

During their work, Sharice notices that she gets impatient with Darrell’s pace of speech and finds herself feeling annoyed with him. She brings this to her consultation group to understand why this is happening and how it is affecting her work with Darrell. Talking about it with her supportive group helps her deal with her emotional reactions more effectively and build understanding for why she is experiencing frustration and how to adjust so she can provide the best service possible to Darrell.

The evidence-based therapeutic alliance

The therapeutic alliance was a psychoanalytic construct until Edward Bordin described it in pantheoretical terms. Alliance factors include three dimensions:

1) The emotional bond

2) Mutual goals

3) Collaborative tasks in counseling

Additionally, progress monitoring and rupture and repair can be viewed as EBRFs related to the alliance.

The emotional bond

Although it can be difficult to measure an emotional bond, in the counseling context it is usually defined as clients showing a positive affective response toward their counselors. In many ways, the counselor-client emotional bond is a natural byproduct of the Rogerian core conditions and of the work that counselors and clients do together. However, counselors lead in this process by greeting clients with a positive affect and consistently showing interest in what clients talk about.

****

When Darrell arrives at Sharice’s office, she is visibly happy to see him. In addition, she expresses her interest in working with him and her belief that he possesses the ability to overcome the issues with which he is struggling.

After a few sessions, Darrell begins to show trust in Sharice. He no longer looks anxious to be in her office, his speech is less guarded and he smiles more during their interactions. He mentions that although counseling is difficult at times, he appreciates having time every week with Sharice to talk about his life and sort out what is troubling him. He has become emotionally bonded to Sharice and looks forward to counseling sessions.

Mutual goals

In the first few sessions, counselors and clients explicitly discuss clients’ personal problems and corresponding counseling goals. Eventually, and sometimes even in the first session, clients and counselors agree on which goal or goals to focus on in counseling.

****

Sharice (after discussing Darrell’s presenting problems and possible solutions): Darrell, we’ve identified several goals that we can work on together: stress management, managing the negative or critical thoughts you have about your work performance and getting better sleep. Which of these would you like to focus on first?

Collaboration on tasks linked to goals

After working with clients to decide on counseling goals, counselors introduce tasks or activities in session (or as homework) that are meaningfully related to the agreed-upon goals. These collaborative tasks often constitute the “technical” part of counseling.

When applying techniques, relationally oriented counselors:

Are careful to listen closely to what clients have already tried

Use reflective listening to gain a mutual understanding of what has worked worse or better

Jointly brainstorm new options with clients

Ask permission to try out technical procedures

Jointly monitor client reactions to new strategies

****

Sharice: We’ve been talking about everything you’ve tried to help yourself sleep better. It sounds like you’ve been working on this for years. How about we rank which strategies have worked better for you and which have worked worse?

Darrell: Sure. (Sharice and Darrell work on Darrell’s rankings.)

Sharice: One of the things I’ve noticed that seems to work better for you is
when you’re able to distract yourself from your thoughts about work. Does that sound right?

Darrell: Absolutely. It’s so hard for me to get my brain to stop problem-solving.

Sharice: One thing I’d add to your list of possible strategies is mindfulness meditation. It can be a powerful technique to deal with racing thoughts. What’s your reaction to that idea?

Progress monitoring

After counseling goals are established and collaborative tasks identified, counselors and clients work together to evaluate counseling progress. There’s a robust body of research attesting to the positive effects of progress monitoring.

****

Sharice consistently checks in with Darrell in two ways. First, she uses the Session Rating Scale after each session to gauge her therapy alliance with Darrell. Second, she directly asks Darrell about his reactions to the counseling strategies they are working on together.

As a part of her progress monitoring efforts, Sharice asks Darrell to keep a log of his mindfulness meditation activities, along with his sleep quality and quantity. Each week, they discuss what went well and what was challenging. She offers empathy and makes adjustments to his homework as needed.

Rupture and repair

Rupture is defined as tension or a breakdown in the counselor-client collaborative relationship. Repair involves counselors making statements and taking actions to restore the therapeutic relationship. Rupture can happen at any time during counseling. Usually it involves clients withdrawing or showing irritation.

****

After a few weeks of logging his mindfulness meditation, Darrell appears agitated. When Sharice asks about the log, Darrell says, “This is a waste of time, and I don’t know why you thought it was going to help. I’m done with this stupid meditation.”

Sharice responds empathically and then explores with Darrell the source of his frustration. She discusses how embracing a passive attitude during meditation can be extremely difficult, especially because of the pressured and problem-solving orientation he has at work. She apologizes for pushing the idea of mindfulness meditation.

Darrell’s response is paradoxical. He spontaneously shares how important it is for him to find time to get out of his hard-driving mentality. Sharice then tweaks the mindfulness approach they have been using. The new emphasis moves away from formal logging and embraces small moments of progress.

The relationally focused, scientifically based counselor

Beginning with Rogers and moving forward into the 21st century, counseling practitioners have embraced the therapeutic relationship as central to positive counseling outcomes. However, at times, allegiance to and emphasis on the counseling relationship has been viewed as anti-science. The good news is that, now, more than ever, we have growing empirical evidence to support the efficacy and effectiveness of a relational emphasis in counseling. In this article, we reviewed and illustrated specific ways in which you can emphasize the therapeutic relationship and be evidence-based. This is welcome progress for the counseling profession in general and counseling practitioners in particular.

****

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

John Sommers-Flanagan is a professor in the Department of Counselor Education at the University of Montana. He has co-authored many books, including Tough Kids, Cool Counseling (published by the American Counseling Association) and Counseling and Psychotherapy Theories in Context and Practice (published by Wiley). Contact him atjohn.sf@mso.umt.edu or through his blog at johnsommersflanagan.com.

Kindle Lewis is a doctoral student in counselor education and supervision at the University of Montana. She is a national certified counselor, holds a license in school counseling and has 10 years of experience working with youth in education and counseling settings both locally and internationally. Her areas of focus are youth and school counseling, community building and holistic wellness. Contact her at kindle1.lewis@umconnect.umt.edu.